,

2008

 , ( ) : . , . , .

70 30 ()- . ()- , . 1994 - - , 85 . , . , , . . .

ART PCP - (Immune reconstitution inflammatory Syndrome) (IRIS) - (Antiretroviral therapy) Pneumocystis carinii (Pneumocystis carinii pneumonia)

1. Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.313). http://www.who.int/tb/publications/cds_tb_2003_313/en/index.html (accessed 29 October 2006). International standards for tuberculosis care. The Hague, Tuberculosis Coalition for Technical Assistance, 2006. BHIVA guidelines for the treatment of HIV infected adults with antiretroviral therapy. London, British HIV Association, 2005. http://www.bhiva.org/guidelines /2005/BHIVAguidelines (accessed 30 October 2006). Briss PA et al. Developing an evidence-based guide to community preventive services methods. The Task Force on Community Preventive Services. American Journal of Preventive Medicine, 2000, 18(1 Suppl):3543. WHO Health Evidence Network. What is the evidence for the effectiveness of interventions to reduce hepatitis co-infection and the associatedmorbidity? Copenhagen, WHO Regional Office for Europe, 2005. www.euro.who.int/HEN/ Syntheses hepatitis C/ 20050412_1 (accessed 30 October 2006). EBM guidelines: evidence-based medicine [online database]. New York, Wiley. http:// ebmg.wiley.com/ebmg/ltk.koti (accessed 16 June 2006). Revised WHO clinical staging and immunological classification of HIV and case definition of HIV for surveillance. Geneva, World Health Organization (in press 2006). Nunn P et al. Cross-sectional survey of HIV infection among patients with tuberculosis in Nairobi, Kenya. Tubercle and Lung Disease, 1992, 73:4551. Harries AD et al. The scourge of HIV-related tuberculosis: a cohort study in a district general hospital in Malawi. Annals of Tropical Medicine and Parasitology, 1997, 91:771776.

2. 3.

4.

5.

6. 7. 8. 9.

10. 10. Tam CM et al. Tuberculosis in Hong Kong patient characteristics and treatment outcome. Hong Kong Medical Journal, 2003, 9:90. 11. Lucas SB et al. The mortality and pathology of HIV infection in a west African city. AIDS, 1993, 7:15691579. 12. Rana FS et al. Autopsy study of HIV-1-positive and HIV-1-negative adult medical patients in Nairobi, Kenya. Journal of Acquired Immune Deficiency Syndrome, 2000, 24:2329. 13. Ansari NA et al. Pathology and causes of death in a group of 128 predominantly HIV-

positive patients in Botswana, 19971998. InternationalJournal of Tuberculosis and Lung Disease, 2002, 6:5563. 14. Archibald LK et al. Fatal Mycobacterium tuberculosis bloodstream infections in febrile hospitalized adults in Dar es Salaam, Tanzania. Clinical Infectious Diseases, 1998, 26:290296. 15. Richter C et al. Extrapulmonary tuberculosis a simple diagnosis? Tropical and GeographicalMedicine, 1991, 43:375378. 16. Bem C et al. The value of wide-needle aspiration in the diagnosis of tuberculous lymphadenitis in Africa. AIDS, 1993, 7:12211225. 17. Pithie AD, Chicksen B. Fine-needle extrathoracic lymph-node aspiration in HIV-associated sputum-negative tuberculosis. Lancet, 1992, 340:15041505. 18. Wilson D et al. Diagnostic yield of peripheral lymph node needle core biopsies in HIV infected adults with suspected smear-negative tuberculosis. International Journal of Tuberculosis and Lung Disease, 2005, 9:220222. 24 25 19. Hudson CP, Wood R, Maartens G. Diagnosing HIV-associated tuberculosis: reducing costs and diagnostic delay. International Journal of Tuberculosis and Lung Disease, 2000, 4:240245. 20. Bekedam HJ et al. Tuberculous lymphadenitis, a diagnostic problem in areas of high prevalence of HIV and tuberculosis. Transactions of the Royal Society of Tropical Medicine andHygiene, 1997, 91:294297. 21. Luzze H et al. Evaluation of suspected tuberculous pleurisy: clinical and diagnostic findings in HIV-1-positive and HIV-negative adults in Uganda. International Journal of Tuberculosis and Lung Disease, 2001, 5:746753. 22. Heyderman R et al. Pleural tuberculosis in Harare, Zimbabwe: the relationship between human immunodeficiency virus, CD4 lymphocyte count, granuloma formation and disseminated disease. Tropical Medicine andInternational Health, 1998:3:1420. 23. Maher D, Harries AD. Tuberculous pericardial effusion: a prospective clinical study in a owresource setting Blantyre, Malawi. InternationalJournal of Tuberculosis and Lung Disease, 1997, 1:358364. 24. Cegielski JP et al. Tuberculous pericarditis in Tanzanian patients with and without HIV infection. Tubercle and Lung Disease, 1994, 75:429434. 25. Reuter H, Burgess LJ, Doubell AF. Epidemiology of pericardial effusions at a large academic ospital in South Africa. Epidemiological Infection, 2005, 133:393399. 26. Archibald LK et al. Fever and human immunodeficiency virus infection as sentinels for emerging mycobacterial and fungal bloodstream infections in hospitalised patients 15 years old, Bangkok. Journal of Infectious Diseases, 1999, 180:8792. 27. Archibald LK et al. A hospital-based prevalence survey of bloodstream infections in febrile patients in Malawi: implications for diagnosis and therapy. Journal of Acquired

Immune efficiency Syndromes and Human Retrovirology, 2000, 181:14141420. 28. Bell M et al. Seasonal variation in the etiology of bloodstream infections in a febrile inpatient population in a developing country. International Journal of Infectious Diseases, 2001, 5:6369. 29. McDonald LC et al. Unrecognised Mycobacterium tuberculosis bacteraemia among hospital inpatients in less developed countries. Lancet, 1999, 354:11591163. 30. Lewis DK et al. Clinical indicators of mycobacteraemia in adults admitted to hospital in Blantyre, Malawi. International Journal of Tuberculosis and Lung Disease, 2002, 6:10671074. 31. Thwaites GE et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. New England Journal of Medicine, 2004, 351:17411751. 32. Mayosi BM et al. Interventions for treating tuberculous pericarditis. Cochrane Database of Systematic Reviews, 2002, (4):CD000526. 33. Elliott AM et al. A randomized, double-blind, placebo-controlled trial of the use of prednisolone as an adjunct to treatment in HIV-1-associated pleural tuberculosis. Journal of Infectious Diseases, 2004, 190:869878. 34. B .. . 2000 . 5-86581-045-6. 1. 2. 3. 4. Bobrowitz ID. Ethambutol in tuberculous meningitis. Chest, 1972, 61:629632. Donald PR, Seifart HI. Cerebrospinal fluid concentrations of ethionamide in children with tuberculous meningitis. The Journal of Pediatrics, 1989, 115:483486. Donald PR, Schaaf HS, Schoeman JF. Tuberculous meningitis and miliary tuberculosis: the Rich focus revisited. The Journal of Infection, 2005, 50, 193195. Donald PR et al. Intensive short course chemotherapy in the management of tuberculous meningitis. The International Journal of Tuberculosis and Lung Disease, 1998, 2:704711. Escobar JA et al. Mortality from tuberculous meningitis reduced by steroid therapy. Pediatrics, 1975, 56:10501055. Girgis NI et al. Dexamethasone adjunctive treatment for tuberculous meningitis. The Pediatric Infectious Disease Journal, 1991, 10:179183. Gundert-Remy U, Klett M, Weber E. Concentration of ethambutol in cerebrospinal fluid in man as a function of the non-protein-bound drug fraction in serum. European Journal of Clinical Pharmacology, 1973, 6:133136. Hughes IE, Smith H, Kane PO. Ethionamide: its passage into the cerebrospinal fluid of

5. 6. 7.

8.

man. Lancet, 1962,1:616617. 9. Humphries M. Management of tuberculous meningitis. Thorax, 1992, 47:577581.

10. Phuapradit P, Vejjajiva A. Treatment of tuberculous meningitis: role of short-course chemotherapy. The Quarterly Journal of Medicine, 1987, 62:249258. 11. Place VA, Pyle MM, de la Huerga J. Ethambutol in tuberculous meningitis. The American Review of Respiratory Disease, 1969, 99:783785. 12. Schoeman JF et al. Effect of corticosteroidson intracranial pressure, computed tomographic findings and clinical outcome in young children with tuberculous meningitis. Pediatrics, 1997, 99:226231. 13. Tuberculosis. In: Pickering LK, ed. Red book: 2003 report of the Committee on Infectious Diseases, 14. 26th ed. Elk Grove Village, American Academy of Pediatrics, 2003:649. 15. Woo J et al. Cerebrospinal fluid and serum levels of pyrazinamide and rifampicin in patients with tuberculous meningitis. Current Therapeutic Research, 1987, 42:235242

1. 2. 3. 4.

. . . . . . . . . . . . . . . . . . . . . . . . . . . 10 , , . . . . . . . . . . . . 28 - , . . . . 61 - . . . . . . . . 75

II

5. 6. 7.

, . . . . . . . . . . . . . . . . . . . . . . . . . 87 , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 , . . . . . . . . . . . . . . . . . . . . . . . . . 115

I.

1. , , . Mycobacterium Mycobacteriaceae . (1997)- Mycobacterium 71 () . M.Tuberculosis ( ()), M.bovis M.africanum, M.leprae . 16-25 M.avium (intracellulare) . . - 10-15 7-10 M.bovis ( 100%) . , 10

. , , . . .

, 0.2-0.61.010.0 . (, , L) . . (R-), . () . , 35-38 . 20-24 . . - , , , , . , ( 40% ) (- ) . , , . - () .

I.

(, , , - , , ..) . : . - . . 100 . 3 , 6 , 150 , . . 70 7 . 10-12 100 45 , 75 30 , 5 . 1 , 260 . 70 30 6 . ( 176 ) . . . - .

11

. () - . , , 57%- , . () . 1999, 2008 29.4 , 42.6 . , , . . - . - . 30 , 20- , 30 , 100- . - , . - . 30% , .

I.

5 , - . - , . , - . , . .

, , . 398 - 72 (), 199 - 87 . - . - 1984-1988 (I), 1989-1994 (II), 1995-1998 (III) . , 1.1- .

- . , . . 1.1

- , (%)
n=72 45.8% 54.2% 47.2% n=87 75.8% 24.2% 20.7%

- (P<0.01).

(P<0.01).

12

I.

1.2- . . - . - . 3 1.2

- , . . , .

- , 1984-1988 (I), 1989-1994 (II), 1995-1998 (III)

-

I , , ( ) , ()

, (%) II
37.2 42.9 40.8 72.0 45.6 69.5

, ( ) III I
90.0 61.3 49.1 27.5 48.5 25.9

III
20.0 51.9 21.1 20.0 27.7 16.5

III
60.0 29.6 32.4 35.0 33.3 14.0

II
47.4 57.5 43.1 25.0 42.5 19.9

I
10.0 16.1 20.8 37.5 23.9 24.4

II
47.4 24.2 29.3 44.4 34.2 21.4

I
0 22.6 30.2 35.0 27.6 49.7

II
5.2 18.3 27.6 30.6 23.3 58.7

III
20.0 18.5 46.5 45.0 39.0 9.5

20.4 32.6 39.8 63.5 39.4 69.0

33.3 56.2 65.1 47.6 57.7 87.0

, , . . ,

: , .

13

I.

. , . , . . . , . , ( L ) . . 10% . , , , , . , , . . , , . - 20 , 20- .

23 . . . . 60% , . . . , , , . 3.5 . . , . . , , , . . 6-12 . .

14

I.

. (1) (2) . . . . . , . 7-14 . , . 14-16 , ( ), . (25 ) . . , . , , -, . , ( , ..) , ( ) . , , , . , .

. , , . . , (, ) , , . , , , , - , ( ..) . : , . ( ) . . 2-4 . , . 20 .

15

I.

: . - , . , , , , , , , , , , ( , , , ). , , , . , . 3 : 1. , 2. , 3. .

1 ( ) . . - , . , , , , , , . , . , , . . 10 . (2-3 ) , (, , ..) . . , ,
16

I.

. , . , , , . . , , , , , , ( ), . , 30 . 50 . , 3.1 . . ,

. , , , , . . 30% 3 . , . , , , . (100.000 ) . . 1993 . - 1.9 . 10-12 , 4-5 . , ( 1.3). 3 , 100.000 35,1 39,9 , 12,0- 13,0- .

17

I.

1.3

* (100 ), 1995-1997 .
1995 17,2 10,6 13,6 9,0 14,9 8,6 7,2 4,5 22,1 9,1 2,7 10,5 5,4 56,8 37,9 12,9 15,0 11,6 6,4 35,1 1996 17,8 10,7 13,3 9,0 14,4 9,2 7,3 4,1 21,0 9,0 7,9 10,8 5,0 53,5 32,7 12,6 12,8 10,6 5,6 38,7 1997 16,5 10,1 12,7 7,3 13,6 10,6 7,3 3,6 17,5 8,5 3,0 9,5 4,7 52,1 33,1 11,1 11,4 10,3 5,2 39,9 1995 8,2 8,0 3,9 4,7 4,7 2,5 2,6 2,0 6,6 2,5 1,4 2,0 1,4 20,6 7,1 4,8 5,8 2,6 1,2 12,0 1996 7,2 7,1 3,6 5,7 4,5 1,9 2,6 0,4 21,0 3,0 1,4 2,3 2,4 19,8 4,6 4,7 5,0 2,4 1,0 13,7 1997 4,5 1,5 4,3 2,7 4,1 2,2 3,6 1,5 17,5 3,3 0,8 2,0 2,3 16,6 5,5 3,6 4,0 2,0 1,1 13,0

*- , 1999

(100.000- 52,1), (33,1), (16,5) . , , , , 3,0-5,2- . ()- . 1997 100.000 81,0- , 25,6 . 78,7 32,3, 51,1 18,5 .

- . 100.000 155,4, 119,3, 101,4, 79,3, 60,5, 56,4, 54,8, 52,9 . - 1990- 100.000 34,0, 14,6 . 22,9, 9,0

18

I.

. 1992 - 2 1998 100.000 76,0- 1970 ( 1.1

1.1). , .

100.000
90 80 70 60 50 40 30 20 10 0 1970 1975 1980 1985 1990 1995 1997 1998 19.0 20.4 16.6 21.0 14.6 25.5 28.3 28.9 72.4 28.5 47.3 45.2 34.2 57.8 73.9 76.0

2 1997 100.000 16,8 . , 5-6 . 1997 5,4 . (2 ). 1997 100.000 28,3- . . (82,0%), 10 2 2%- . , 1990 100.000 7,8 1997 14,7

. 2,4- 99,8, 104,6- . (100.000 9,8), (9,6), - (6,7) (7,4) . , (100.000 31,6), (28,5), (24,0), (23,0) . - 2,2 . : 110 , 200 , 700 ,

19

I.

, 300 .

. . 1990- 1.2

. ( 1.2), 10 100.000 4,0- . 1970-1991 - 2,1 (100.000 72,4- 34,0) 3.5 (10,2- 3,2).

, (100.000 )

80 70 60
58.5 72.4 67.5 57.9 47.4 48.0 42.9 34.2 34 35.8 74 76.0

50 40 30 20
10.2 45.2

10 0
1970

5.1

4.5

3.2 1990

3.2

3.3

3.4

3.5

3.6

3.4

3.4

3.5

1975

1980

1985

1991

1992

1993

1994

1995

1996

1997

1998

1992 . 1992-1998 - 112,3% (100.000 ), 1.4

6,1%- . 1970 14,0%- 1998 4,6% ( 1.4).

, , 1970-1998
1970 1975 11,9 14,35 1980 10,8 16,04 1985 9,9 16,63 1990 9,4 12,47 1991 9,4 12,8 1992 9,2 12,9 1993 7,9 12,8 1994 7,3 12,1 1995 6,2 11,5 1996 5,0 10,6 1997 4,6 9,8 1998 4,6 9,1

14 15,9

20

I.

1/4 - (, , ) 1/3 (), 1/2 () . , . , . 36% - . , 1.5

. , (100.000 1,1- 26,0 ). (, ) . 1998 - 1,9, 4,4 ( 1.5).

- - , 1998 , 100.000
( ) , 1,20 0,73 1,07 1,25 2,03 0,97 0,49 0,94 1,17 1,57 1,2 0,49 0,56 0,5 0,89 0,8 0,6 0,29 1,34 0,6 0,54 0,58 0,82 0,51 0,53 0,51 0,62 0,36 0,4 0,23 0,12 0,71 0,52 , 0,52 0,44 0,32 0,76 0,5 0,3 0,2 0,5 0,64 0,41 0,44

3,1 2,2 2,7 3,7 4,4 2,7 1,9 2,7 3,0 3,6 3,1

2 (35,5%/12,5%) , (100.000 1989 3,7, 1998 3,3).

. .., ..

21

I.

1986 , 100.000 4,0- . 1990 2,5 . - 2 . 1987-1990 1991 , . . 1.3

500 450 400 350 300 250 200 150 100 50 0

. 1000 3,1 2,6 . 1970 - ( 1.3). 1992 . 1970-1992 70,0%- (100.000 75,3- 22,2 ) 1992-1998 4,5% (22,2- 21,2) .

, (100.000 )

472 367.2 256.8 220.9 188.3 177.7 172.5 174.9 180.0 191.4 205.5 219.9

234.1

75.3

52.7

41.1

36.6

23.5 1990

22.7 1991

22.2 1992

22 1993

21.9 1994

21.9 1995

21.7 1996

21.5 1997

21.2 1998

1970

1975

1980

1985

1992 ( 1.4). - 6,8% (1970 15,9% 9,1% ).

22

. 1951 1/5-, ( ) .. . 15 (1971 ) .. (-

I.

87,6%-, 91,3%). 20 . .. ( ) 0,9%, 0,3%, 1,1%, 1,6% . 0,6%- . 80- (19,8%) (18,7%) (1984 7,4%) . 1990- . 1992 28,6%- . 8,4 . 1992 12,8 . . - (68,072,0%) (59,0-63,0%) . 5-39 (78,0% , 94,0% 5-14 ) 40 (75,0% ) . , - .

. . . 195564 .. 88,0%, 12,0%- 77,8% 22,2%, 58,7% 42,3% . . 7080 46-49, 50-54, 55-59 . . (60-69 70- ) - (19- , 70- ) . , 19 , - . 90- . 2-3 . - 19911998 9%(100.000 3,2 3,5), 27,0% (0,8- 1,1) . - 90-

23

I.

. 1997-1998 1.4

( 1.4).

1997-98 1991-1993
45 30 15 0 0-19 -15 20-39 0% 40-59 -11% 42% 27.0% >60

. .. ( )- 58%, 30,4%, - 8,3%, 1,7%, 1,6%- . 50-60 36,2%, 32,8%- , 5,8%, 1.6

8,6%- . 60- - (27,1%) (24,2%) . (21,7%), 20,4% . 70-80 . - , ( 1.6).

- 1971-1984

1971 1975 1976 1980 1982 1983 1984

29,1% 35,8% 37,7% 40,5% 41,7% 42,2% 42,6%

- 19,4% 17,6% 18,9% 16,7% 16,9% 17,9% 17,6%

18,8% 18,6% 18,3% 16,8% 16,2% 14,7% 15,1%

4,2% 3,9% 3,1% 3,1% 3,3% 2,9% 2,8%

28,5% 24,1% 22,0% 22,9% 21,9% 22,3% 22,0%

24

I.

60- - 50%-, 42,9%, 52,2%, 29,9%, 42,2%, 26,7%-, 4,8%, 0,69%, 0,2%, 4,6%, 3,0%, 18,0%- 1.7

. 1965 - . , , . ( 1.7).

, 1971-1984 (%)

1971 1975 1976 1980 1982 1983 1984

, 27,1% 34,2% 35,8% 40,8% 42,6% 42,6% 43,8%

, 29,0% 24,3% 23,5% 20,5% 19,2% 18,8% 18,4%

15,3% 17,9% 17,8% 17,5% 17,2% 16,9% 17,0%

3,1% 2,5% 2,3% 1,9% 1,9% 1,9% 2,0%

25,5% 21,1% 20,6% 19,3% 19,1% 19,8% 18,8%

1.6 1.7- 70-80- , . , -, . ( 33,3%-, 35,5%-). - . ( , ,

25

, ) . (30-40%) . , - ( 1.5). - 3 , (100.000 1,23-1,37) (0,42-0,70) .

I.

( 1.5). , 1.5

. , .

, 1976-1998
10% 21% 11% 41% 11% 16% 12% 45% 32%
,

12% 22% 11% 36% 17% 1976

16% 20% 18%

2%

15% 1980

2%

14% 1991

3%

14% 1998

2%

. 1995-98 0-4 ( 1.6). , 40- 16-22%- . 10-19

, 60- 8%- . , (39-41%), (21-26%) . 412%- .

26

I.

1.6

, (1995-1998 )
12% 4% 8% 22% 10% 14% 9% 8%

9% 9% 9% 4%

33%

47% 20% 21%

20%

21% 70% 30% 17% 2% 2% 0-4 5-9 2% 10-19 4% 3% 20-39 5% 4% 40-59 16% 26% 41% 36%

39%
,

22% 1% 60-

, . . , . 3 (100.000 0,37-0,66) - . - 1995-1998 - 04 . 5-19 ( 1.6). 0-4

27

- 31,3% . . . 1992-1995 . . , , . - . , , , , ,

II. , ,

. . - 90% , 40%, 67% , 10 . , , (40% ), (12%) . ( 40-60 ) . - . 22-38%, 23-37%, 50% . , . , , 10 2 . - 1998-2004 . 12-30%- .

. . . 2. , ,

: - , , , , , , , , , , , , . . .

28

II. , ,

. - , .. .. . 1959 ( ) . . , , . . . , , , , , . , , , .

, . , , . , - . . , - - . (4,5 ) . , , , . - , , , . ( 2.1).

29

II. , ,

2.1

. 1.5 , . .

. , ,

( 2.2).

2.2

() . () . (1) . (2) . . . .. , 5 .

30

II. , ,

, , , , , , , , , . , , . . , . : ( ), , ( ), , , . . , (70-80%) . ( ) . , ,

. . , , ( , ) . . . , . , . : - ( 2.3), , , , ,

, - , , , .

31

II. , ,

2.3

2.4

, 40

. , . , , 60 .

, , . , , . . . , . , . ( ) : ( ), , -

, ,

( , . ). , , ( ) . , . ( , , ..) , .

32

II. , ,

. . . , . , , ( ), , , , ( ), , . 2.1

, . , , . . , , , , , , , ( 2.1).

(, , ) (, , , )

, , (, , , )

. ,

( ) .

33

II. , ,

- . 2.5

, , ( 2.5).

( ) . 1-, 2- , 3- . . 1 , 2- , 3- , 4- .

, , ( 2.6). ( 2.7).

2.6

2.7

- . . , - , 80 .

1- , 2 , 3, 4 .

34

II. , ,

, -, 2.8

, ( 2.8).

1- , 2- , 3- , 4- , 5- .

, , ( 2.9). 2.9

- 1- , 2- , 3-, 4 , 5- , 6- .

( ), 1/3 . , .
35

, , , ( 2.10).

II. , ,

2.10

1- , 2- , 3-, 4 .

, - . 4 . , , . - . 2.2

. , : , - , , , , , ( 2.2).

, , , .

36

II. , ,

( , , ..) , - . . - . , , , . , , . , . . 1980 - . , - . - . -
37

. . , . . , . - () . - . , .. -, . ( ) , . ( ) . - . (, , , , ) ,

II. , ,

, , , , . , , , . . , , - , . , - ( ).

. . , , , ( 2.11). , , . ( , ), . (, , ), -, ( , , ) , . , , . . - , , . ( )
38

- , , . ( )

II. , ,

. , 2.11

(-) (-) .

( 2.12), , 2

. , .

39

II. , ,

2.12

, . -1 - 0 2 , 12 - 1 . - 1 0 , -2 . - 2 4, 5, 10 - - , - . , . - 0 - 1 ( ) - 2 ( ) .
40

- 1, 2 . ( 2.12) , , . ( ) . 80-90%- , , . , , , ,

II. , ,

, . () / / . - - . : -2 12- - 1 , -2- . -2 , . -2 - - . .

() . , , , - , - - . . . - , . , , . , . -2 - , - , - 2- - 4, 5, 10 . , . - 1- ,

. .

41

II. , ,

. - 1- . . . - 2- , . . , . (IgE) , , , , . (, ) . - . , , , . . , , - 1 2 ,
42

. , , - . . (HLA) . , , , . HLA B DR , . , (Hp) (Gc, ) . 2-2 Gc 1-1, , HP 2-2 - Gc 1-1 . , . - , - ,

II. , ,

. . . (, , ) . , , . , , . . , , . . , , . , , .
43

, . , A G, , , , , . , , . , - , , . . .

II. , ,

. . 10 ( ) . 18-19 . . 15 16 ( ) . 18 18.2- . , 18.3- ( ). . - . () . , , , ,

, , , , , , . , , (, ) . , , . . . , . . . .. . ( 2.13)- . , .. .

44

II. , ,

2.13

( , -)

- . , , , , , .

. , , . .. . .

45

II. , ,

. : 1. . 2. . 3. . 4. . 5. .

. . , , , // . , , , , , ( , , ..) . , . , . - . , . - . //

. . . , . . . , . - . , . . , - . . - , . , , , . ,

46

II. , ,

, , ( , , ) . - . , . . , . , , , . , , , , .. . () . . . ,

. . , . .

,
. 1. , 2. , 3. , 4. , 5. , 6. , 7. ( ..) - .

. ( .., 1987). . , . ( 2.14),

47

II. , ,

. .

2.14

. , . , . , . , , , , . . . . , , .., .. . ( 2.15), , . . . .

, , . , . , . , , .

48

II. , ,

2.15

- . , , . . . , , , , , . . , . , , , . , , . (, , , ) . , . , .

, -

. . , , . , , , . () , , . , , . () . . , () . , , . ,

49

II. , ,

,
, . , (X, XI, XII) (I,II) . , . () , ( 2.16). , 1-2 . , . - , 2.16

. , . . 4-5, . (15 ) . , . : . , . . , . , . , (). . , . . ( ) , - .

50

II. , ,

, . , , . . - . , , , . , , , , . . . 2.17

. . . , () , . V.Menard, .. ( 2.17). , . ( 2.18).

2.18

51

II. , ,

2.19

, . , . (2 ) , . , , , (2.19). , ( 2.20). . . , . . . . .

2.20

. () .

(, , ) .

52

II. , ,

.. . , . . 2% . ( ) ( ) . , , , () . , . , . . - . . . ( 2.21). .

2.21

. , , . . () , . () () , . ,

53

II. , ,

. . , . , , () . .. 44% 75% . 62%-, 18%-, 20%- . - . . . , , (? ) . , . , .

. , . , , - . ( , ), (, ..) . . ( , , , ) . , , , . , ( ) . . , , , .

54

II. , ,

() . . . , . , . - . , - . . - , . , , , .

, , , - () , . , . . , . . .

: , (), . . (18%) (82%) . ( ). , . , . () . . ,
55

II. , ,

, . . . . . , . . . .., .. (67%) 21-60 . (75%), (20%), (5%) . , (20%). 40%- . 16%- , , . .

29%- . 4%- , , 11%- (, , ) . . . , ( ), , . ( , , ) . () . ( ) , , ( ) . , ( ) . (, ). , . 60%- . , , .

56

II. , ,

. ( ), , . . . (, ) . ( ). . , . . () . ( , , , , ) . , ( ) . .

, , . , . . , , .

,
, , . . , . . , . . . , , . () , - . , .

57

II. , ,

. , . , ( , , ) . (, ) ( ) .

. . . . , . , , , . (, ), . () . . , . , . . . . . .. . . . .. (1986) 324 56 (17%)

. , . . , , . .. (1986) 380 100% 24%- , 5.8%- . (70.8%). 2 : 1) , 2) . , . , .

58

II. , ,

. 53- , 3- . , ( ) .

, . . , . () . (, ), ( , , ) . (, , ) . . , , . .

. , , , . , . , , . , -, . . , . . , . . ,

. , . .

59

II. , ,

. - , , . , . , , . 3 : , , . . , . . . , , , . , . . . . , , (, - ) .

. .., .. . ()- . , . 21%- . - . ( , ) (, , , ) . () . - . . () . , . 1012 .., .. . (), () , - .

60

III. - ,

. (, ), ( ), ( , , , )- . . , . , , . . , . . , . , . ( ) . . , . , .
61

. 3. - , () . - , , - . - , - . - , , . , , . - . , - , . - - 2003 , 2006 - (Stop TB Partnerships)-

III. - ,

. 2003 - - , : - . . , . - , . , /- , . - 1%, - 5% , (, .) ( , .) - . - 1% , - - , - - ( , ) , . - , - , - , . - -

, 2005 9 - . , , . - . , , , . , , . - , - , (STAG-TB) - , (STAG-HIV) . , , ( 3.1- ) . . , .

62

III. - ,

, II , , . . , 3.1

, . , , - .

I. , II. , III. , - IV.

. .

. , - . , - - . , , . , ,

, , , . . , - , , . .

63

III. - ,

- () -

- .

- 1 . - 2 - -

:
: - . , , - . - , . : , /- (: IV). - , (: -II).

- 1

- Mycobacterium tuberculosis- - . Mycobacterium tuberculosis- - -

, - .

64

III. - ,

, - , (: -II). , (: -IV). , (: -II). , , - , (: ).

(: -II). , . , , , (: -II). , , (: ). , , , (: ).

: - , - . , - . : - - (: -IV).
65

: . ,

III. - ,

, . - - . , . : , , , - , , (: -II). - , , , (: -I). , , . . (: ).

. . , , . 3 . . . . : , , (: -IV). - , (: -IV). , (: -IV).

()
: -

:
66

III. - ,

, - . - - 4 ( ) , - , , . , , . - , . : , , , (: ). . , . , , (: -IV).
67

(: -I). , - . , (: ).

: - . - . : - 2003 (: ). - , . , (: ).

-
, ,

III. - ,

, , , . /- . 2-3 , ( ) .

. - - . : - 2-3 . ( ) - . : - ( 3.2- ), (D4 ), - , . , 4 . : , . , , . , . : ; -

68

: ( 3.1, 3.2) / - / , . - - , 2006 (2)- , (- 2003 ) ( 3.3). : : - 30- 39- . - 120-

III. - ,

; , ; , / . . : Pneumocystis carinii

(PCP) . Pneumocystis carinii , . .

3.1

-
2-3 a

2 3 4

PCP

69

III. - ,

: >30/, >39, >120/, . - 1% - 5% . - / . - ; - 2 . , . , D4 , . , . PCP, Pneumocystis carinii , Pneumocystis jiroveci . ( ) .

( ) . - , . 4- . , , . () . - : : . . :

. . : , , . . . : ( ) . ( .) . ( ) PCP- . . :

70

III. - ,

, ( ). PCP . PCP .

- . . - . . 3-5 , . . - . , . . , .

. . , , . . PCP .

71

III. - ,

3.2 -
2-3 ,

, ,

, PCP ,

3-5

3-5

: >30/, >39, >120/, . , . - 1% - 5% . ( ). PCP, Pneumocystis carinii , Pneumocystis jiroveci . - / . - ; - 2 . .

72

III. - ,

3.3

- ( , 2006)

( , )

: (1)- .

73

III. - ,

3.2

, / - -
( <10%) (, , , ) ( >10%) (37.5 , ) ( , , , , , ) , , (<8 /dl), (<0.5109/) (<50109/3) Pneumocystis ( , - ) ( , , ) ( ) , ( , ) ( ) ( ) -

1 2

: (7)- . . . ( , - ( / ), .).

74

IV. -

4. -

. , , . . , , ( 4.1).

- - . , () - () , . , . , . 4.1

, . , , . , , . , 15-25 ( ) . ( ) .

. 9-10 .

75

IV. -

. 3 ( , , ). . , . , . , () . . 0,4-0,6 . . , 0,5-1,0 . , . , , () . , , . . ,

. : , . - , . - . - . , . , . , . , . . , , .

76

IV. -

- () . , , , . - . 1982 , . -180- 10 . ( ), 3 . ( 240, 270, 300) . 4.2

. , . , , , . , , ( 4.2). () , , . . . 98,5% . . , , .

. : 11-12 , , , . . .

77

IV. -

, - . . () . 4.3

. , , . , , - . , ( 4.3).

: 3 , , , (-)

, ( 4.4). 4.4

: -, - : , 2 , , , , ()

78

IV. -

: -, - : , 2 , , , , () - . , . - , . . - - () . 4.5

. . , , , . , , , . -1 , , . -2 , . ( 4.5).

- : , . .

79

IV. -

, . - : , , , , , , , - , , , , , . - , . (-,
80

) . - , , , . . . . , , . , , . , , , .

, . . , . , .

IV. -

. , . . , . . 20-30 - . 1012 , () . , . , 6-10%- . (-1500, .) , . , 0,5-1,0 . , , , , . , , , . , ,

81

. , - . , . , . , . 20-25 . 34 . . , 1 - , . , . . , , . , . , . .

IV. -

(1824 ) . , . , 40-45 . . . . , . . , . , . 4.6

, . , , . . , , . , . , 3,5- . . ( 4.6). - .

. , . - .

82

IV. -

, ( 4.7), , , 4.7

. , - ( ) .

, , . , . , , . .

. , , , . , , . . . , . , , , (, , , ) . , , , , , .

83

IV. -

. ( , , , , ). , () , (- , ) , , , -, ( , , , , , ), , , , - ( , ), , .
84

. . , ( , 8-9-10 ) . 10 . . . , . . . , . , . . , , . , / . .

IV. -

, . . 70 . . . , , . .

. , . . : , , , (, , , , , ), , . , , , , , . , , . , .

80-90%- , . , . . , , , . , - , ,
85

, , .

IV. -

. , , , . . , . , . (, ).

, , , . , , , , . - . , , , , ( ) . - . .

86

V. ,

5. , , , (), (), , . . , . . , . 6. - (- )

- 5- - M. tuberculosis . , , . , , .

1. ( ) 2. ( ) 3. 4.

, :

5.

87

V. ,

, ( , ) . , . , . , , . ( ) - .

- 0-4 , 5- . (15- ) ( - ) . , . - . .

1. ( ) . - ( .) . - - . .

. : , 21 . , 14 38 . , .

88

V. ,

. 2. ( ) . ( ) . . : . : , ( ) , , . . :

, . 3. M. tuberculosis- , . . . . 5 () ()- 2 -23 . , ( 1- ). - : (- , , .. ) 5 (- () ) 10 . ( .) ,

, , , ( .) ,

89

V. ,

. . - / , . - - - . 5.1 . , 2-3 , ( ) - . . 4. , . , ( ) . , ( ) . - , .

, M. tuberculosis- . :

- . - . . (10- ) . , 5 -- . - ( ) . (5- ), . 3 : ( ), ( ). . . . 3 .

90

V. ,

. , , . , . 2- . , , . 5. . . - . 5.1

. . . , . - , . - . - , . - . . 5.1- . .

- ( ) ( ) , , , ,

( ) ( , ) -

91

V. ,

. ( .) , , . . , . 6. - - - - . - , - - .

, (iii) , (iv) . - , - , , . . , - : - ; - - ; - M. tuberculosis- . - . , -

(M. tuberculosis- ) . , . : (i) , (ii)

- . , . - :

92

V. ,

- ; ; , . . . - - . .

1. - : -

. 2. - : -

. - , . 3, 4 - .

93

V. ,

1
, , , (- ) , . M. tuberculosis- . 5 () , , . 5 - 2 23- .

2. - (0.1 - 5 ) , . (- ), 27 . 0.1 . 3. ( 1.1- ) 5-15 , . . 4. 8-10 . 5 . 5. ( , , , , .).

1. 5-10 - , , . (, .) . .

5.1

94

V. ,

48-72 . 72 . 1. , . 2. . 3. . 4. , 0 - . - (- ). 5.2

5. . - . 0 .

- : , . 5 : - (, ). 10 : ( ).

() -, -
-

- , - ( , ) (6 ) (, , ) ( .) ( , , , .)

95

V. ,

2.
: , , .

. , . 4. , . . . 5. .

.
, . ( .) , . 3 : - ( ), , - ( ). ( . II. (1)- ) 1. ( ) . 2. . , . 3. , . . , .

.
M. tuberculosis . . , . - ( - ). . . . 3 (

96

V. ,

) 25-50% . . , . . 3 . - . . ( , ). 4 ( 3 ) , . : - (10 ) - 5, 10, 20, 30 3 ( ) (0.9% NaCl) (8%) /.

, ( ); ( ) . 4 ( 3 ) . 1. . 2. . 3. . . 4. , . 5. . 6. , . 7. (2-5 ) . 8. : ( ). ( (3-5 ) , ). 9. 5-10 . (- , ).

97

V. ,

. 10. (510 ). 11. ( ) . 12. ( ). 1. / . 2. . 3. ( ) (4 ) . 4. (4-8) . 5. . . .

, , .) . - - . , , . , , . . : : 3 , . ( , , ). . : , , ( <50/). , . ( ). 1. ( .) . 2. (3%

.
, . , (

98

V. ,

NaCl) 15 5 3 . 3. , . 4. . 5. ( ): (i) , (ii) - . , .

, - () . M. tuberculosis- - - . . : . M. tuberculosis- ( ) . 4 . , . , , , . : , ( ). 12 , ( 12 ).

3
-

/ , 2 . , , , . 6-9 . , 9 . - , 12-18 , 2 .

99

V. ,

, . - ( ) M. tuberculosis- - :

, , . 25 / . 5.3- - ( ) .

5.3 - -
( () /) 15-20 1000

, ,

, -

, , ,

15-20 7.5-10 7.5-10 7.5-10 20-30

800 1500

15-30 15-22.5 15-30 10-20 150

1000 1000 1000 1000 12000

4.

, , , . ,
100

, . .

V. ,

(60-70%) . ( ) .

, 2 . 5.4- . . - 5.4 2HRZS

. , . 2 . . , , 6 . . (, ) .

4HR Treatment of tuberculosis. Guidelines for national programmes, 3rd ed. (1) Tuberculosis. In: Red book: 2003 report of the Committee on Infectious Diseases, 26th ed. (2) Donald (3)a

2HRZ (S Eth)

7-10HR ( 6 )

6HRZEth

Eth, ; H, ; R, ; S, ; Z, .

101

V. ,

( ) 2 /, 4 . 1-2 . 4 / ( 60 ) , . , . . - ,

- . , . ( ) - . . - - , . 3, :

- . - Pneumocystis jiroveci ( Pneumocystis carinii ), . - , . . ,

( - 5 ) - .

- . - ( - ) - , , .

102

V. ,

- - 6 . - , 9 , 12 (1) . - - . 6 . : , , , . 9 6 . - - . , . - 5.5- .

(SMX); 5- 80 (TMP) + 400 (SMX)) - , . - , - , . - (2) - . .

(ART)
- , ART - . - ART . - , . - ART , ( ) . , .

(5- 20 (TMP) + 100
103

V. ,

80% , 2060% . - (http://www.who.int/hiv/mediacentre) . , (http://www.cdc.gov/nchstp/tb/) . ART , ART . 5.5- - ART . - : (2-8 ) ART ; ART- ; ART- .

ART (. ) ART- 2-8 . ART , - .

, ART . ART 3-6 , 10-40 . ART . ART (3). ART 6 . ART 6 ART . ART . . D4 ( 5.2, 5.3- ).

104

V. ,

5.5

- ART
ART , ART ( 2-8 ) : ART ( 2-8 ) ART 2-8 , - ART D4 : ART D4 , : ART ( 2-8 ) : ART , ART , ART . ART 3- : NRTI - d4T AZT+3TC+ABC : NRTI + NVP 3- : NRTI - d4T AZT+3TC+ABC : NRTI + EFV ART .

4 ( ) 3 ( , )

ART NRTI+ NNRTI - .

ART, ; NRTI, ; d4T, ; AZT, ; 3TC, ; ABC, ; NVP, ; EFV, ; NNRTI, . : Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards universal access. Recommendations for a public health approach (3). (ART ). : . / - . 4 D4- ART . NVP- . . EFV- <3 <10 , , , 3 . D4 5%- 5 D4 200-349 /3 ( 5.6 ). D4 .

105

V. ,

5.6

-
D4 11 (%) >35 30-35 25-30 <25 12-35 (%) >30 25-30 20-25 <20 36-59 (%) >25 20-25 15-20 <15 5 (/3) >500 350-499 200-349 <2000

: Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards universal access. Recommendations for a public health approach (3). <15%.

, - . , - - . , . , - - , - , . - . , .

- - . . . , / - . - .

- ( )
, . M.bovis ,
106

- . -

VI. ,

15 / ( 300 ), 20 / ( 600 ) . - - . 6. , 5 1 . : ( ), ( ) ( ) . : . - - . . , , , . , 6.1- . 6.1- ,

107

. . . . - . : . . ( ) , .

, , , 2 - . : / - , , . ,

VI. ,

( ) . , 85%- . . , . .

- , , . : - ( , , ) , .

108

VI. ,

6.1

()
, , (- ) / ,

- >37.5 (/ ) / ( , ) - , ,

, - .

. , 95%- . -

109

VI. ,

2 (20% ) . :

. , ( 6.1) . ( 30 / ), ( 50% ) . 7 . , , .

, . , . , , 1, 2 . , - . , 6.1- . () . ,

: , , 5 - , 18- 21- *, 3 , ( , .). 1. , . 2. . 3. . 4. ,

110

VI. ,

5. . , . 2 . , . 6. , . . 7. . , . . 8. , . * (18 19G: ), (21G) . - .

, . / , , . . 6.1- , . ( .) . - . : : - 90% (50-70%) . . , . -, , ,

111

VI. ,

. 6.1- , .

, 2 -

, . - . . , - . .

112

 6.1.

() ( ) , , ( ) ( ) (2 ) , , ( ) ( )/ / /

( ) (18-21 )

( ) ( ) , , ( ) /

2 / // , ,

: - , - , ,

, , , , ( )

VI. ,

113
( ) ,

, ( ) 2 ( ) , , (, ) + , , , ( >30/) , +

( , ) / : - / ( ) - ( , , , )

/ ( ) ( , , ) ( ) ( ) , , 7

+ ( ) ( ) + ( ) + +, .

, , - + , ( .) - 2

, , : 50%, >30 / , 7 .

, () . .

 5.5
, , ,

-
, , , , ,

M. tuberculosis

, , (- )

Streptococcus pneumoniae, Haemophilus influenzae, Salmonella spp., Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli ,

, ,

, , , ,

VI. ,

114
, , , , (, ) , ,

, , , , ,

, , , , ( )

Pneumocystis jiroveci

Pneumocystis jiroveci

( )

, , . .

VII. ,

7. , , . - , (., , 6 ) . , , . , . - , . . , . 5-

5- . 2 . . , . , . . , . : (., ) (., - , 5- ) .

( -) 5- ( ) ; 5-

115

VII. ,

. ( 7.1). - - . - 7.1

. . , 5 /- , 6 . 2 . . .

5-

5-

, 1- . 5 /- , 6 ( 5 /- , 6 )

- -

. -

116

VII. ,

. - , - , .

. - , - , . - , .. - , ( 7.1- ) - . - / .

-
- - - , , - 4

-
- > 1% ( , , , .) > 5% > 1% 5%-

, . M. tuberculosis- . - 2 . - .

- - - .

2-3 . .

117

VII. ,

. , , . - , . 6 . . 3 , . . 3 , .

. , . . , . , , . , , . . . . , . ( 7.2).

-
- , . , . - , : 7.2

(/) (/) (/)

-, -; - - - .

118

VII. ,

- , , - . , , . , , , . , , . 2 (0-4, 5-14) , , . ,

. : , , , , . ( ) , . , . . - , , .

119

VII. ,

120